Self-management key to beating obesity in youth.
Such questions help you zero in on how the patient and family view his or her weight, said Dr. Dietz, who directs the division of nutrition and physical activity at the Centers for Disease Control and Prevention, Atlanta.
Useful questions for the patient and family include:
* "Are you concerned about your weight?"
* "Has your weight caused you any difficulties?"
* "What things in your life do you value most? Does your weight influence your ability to pursue those values?"
Tying weight to a child's values "'is an important strategic step," he said. "Rather than rely on external motivation, we need to focus on internally motivating patients and families. The key to success is successful self-management. In this context, ... [care] changes from a provider-directed care to a patient-centered care."
One way to gauge the patient's readiness to make a behavior change to lose weight is by asking, "On a scale of 1-10, with 10 being very interested, how interested are you in changing your behavior?"
Then ask, "On a scale of 1-10, with 10 being very confident, how confident are you that you can change your behavior?"
If the patient expresses a readiness to change, consider these three questions:
* "What might you want to do about this?"
* "What is likely to get in the way?"
* "Where do we go from here?"
If the patient is not ready to change, say something like, "It sounds like you are not yet ready to make a change. Perhaps we can think about what we have discussed and we can talk about it again."
Dr. Dietz said that the majority of focus for overweight and obese youngsters should involve altering diet, increasing activity, and decreasing inactivity.
The current pediatric recommendation for physical activity is 60 minutes daily of moderate physical activity most or all days of the week. This is derived from the impact of physical activity on cardiovascular disease, not on obesity. In adults, the dose to maintain weight after weight loss is about an hour of moderate physical activity per day. "I think that may be a higher dose than is needed to prevent obesity in adults because of the synergistic changes that occur with the offset of obesity"
Nearly everything known about successful strategies for weight maintenance comes from studies of adults. These strategies include low fat intake, eating breakfast, expending at least 400 kcal per day on physical activity, and monitoring weight at least once a week.
Reducing the amount of TV viewing at home is another important strategy. "Interestingly for families, the content of television is a much greater concern than the time their children spend watching television, yet it's the time that children spend watching television that seems to predict obesity," he said.
Dr. Dietz estimated that about half of families in the United States watch TV during meals. "Changing the perspective on meals as the potential family time may be an important strategy," he commented. Also, "families are much more concerned about the time their children spend watching television during the week because it interferes with homework. They're not concerned about weekend TV, which is when children are exposed to food advertisements."
He added that some parents worry that if they control their child's television viewing time, they'll have to entertain them. But when children are asked what they would do if they didn't watch TV, "they provide a whole list of activities, almost none of which involve parents," he said. "So a strategy [of] asking children what they would do rather than watching television may provide some important ideas."
He called the current lack of reimbursement for primary care office visits related to obesity a "significant concern." However, he said that Blue Cross and Blue Shield of North Carolina covers up to four office visits for enrollees who are obese. "That's not enough, but it's a start," Dr. Dietz said. "Increasingly I think insurance companies are going to move in that direction."
San Diego Bureau
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|Title Annotation:||Clinical Rounds|
|Date:||Apr 1, 2006|
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